2001-394 TOWN OF QUEENSBURY
2 Ba Road ue nsbu Y 2 04-5902 518 761-8201
os 74 y ,Q e ry,N 1 8 ( )
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20010394 Date Issued: Wednesday, June 13, 2001
This is to certify that work requested to be done as shown by Permit Number P20010394
has been completed.
Tax Map Number: 523400-090-000-0004-025-000-0000
Location: 23 HEINRICK Cir
Owner: THOMAS & BARBARA QUARESIMA
Applicant: THOMAS & BARBARA QUARESIMA
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
ral` I y/
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)Wiftl
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20010394 Application Number: A20010394
Tax Map No: 523400-090-000-0004-025-000-0000
Permission is hereby granted to: THOMAS &BARBARA OUARESIMA
For property located at: 23 HEINRICK Cir
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: THOMAS &BARBARA QUARESIN Septic Alteration Residential
23 HEINRICK Cir Total Value
QUEENSBURY,NY 12804
Contractor or Builder's Name/ Address Electrical Inspection Agency
SANITARY SEWER
DAN DRELLOS
PO BOX 224
GLENS FALLS NY
Plans &Specifications
2001-394
SEPTIC ALTERATION AS PER PLOT PLAN SPECIFICATIONS
$25.00 PERMIT FEE PAID - THIS PERMIT EXPIRES: Wednesday,June 11,2003
(If a longer period is requited,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the To n o ueen "ff, d ,June 11,2001
SIGNED BY for the Town of Queensbury.
Director of Building&Code nforcement
Application for Permit—Septic Disposal System
Milli q f Qneensbin y 7.12 Boy Road Queettshwy, Ni' 1280,1 (Sly) 761-a 256
1. OWNER INFORMATION:
•
• Location of installation: 2-3 /Te,,i 2-1ck er.c_c,GE Office Use
Tax Map No. / / File Permit I`OgO 3--
9
' �1 o>+.L � tJ iL Fee Paicy:%�C� — ,—
Owner s Name: esi "--1 A ______
-
1-1-et,)
Address: . 3 r2. t c k C t i2 G t IE •
2. INSTALLER'S NAME : crA N ,•r-y{ e..) PHON
7 E NO.
3. RESIDENCE INFORMATION: (circle yea,'oftlwelling, indicate /I bedroom(s) and inullipla of
bedrooms with applicable gallons per bedroom to equal total dail>3Jli ) . .
a .mod,,....4 R �f ii:4
Year of blouse; . No, of Bedrooms x Computation .,--, 'Total Dail Flow JUN
iott,
1980 or older S x 150 gal/bdrnt — 7O" P1g�J t`'r' ~
1980- 1991 x 130 gal/burnt •— ��`G ,ziAs j,�` 1;Ff.`
1991 —present x 110gal/1)dr1l ,--
Garbage Grinder Installed yes / no
Spa or Whirlpool Installed yes / no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
T rapt S _'kta are gi and Water Bedrock or i
Impervous Material _U
• -...__._._... 1 t Water Suyhly
sat!sll at what depth at what depth noon •
liollhtg own feel fuel
Sleep slope clay !f well; water supply
• slope other fi•vat arty seplic-syslem
depth: is Ji.
Percolation Test: (To be completed by licensed professional engineer or architect) ether_
Nate: minute per Inch
5, PROPOSED SYSTEM: Fur New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning IJoartl aprpnovetl subdivision). Add 25(1 gallons to the size
• of the septic lank and leach field fur each Gatbagc Grinder, Spa or Whit Itoul Tub.
i e x',P',NA>
Septic Tank: 1 ° gallon (min. size 1,000 gal)
Tile Field: each trench A)1/a"fl, Total System Length: fl•
Did. De`,
Seepage Pit(s): number of t - size of each: 1'7' fl, by P fl.
' Sizo of Stone to be used: I! i / depth or thickness, 6 -f(,t,l.
Hod System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required) .
•
Number of tanks: _______ / Size of each: gallons /'I'O'1'AL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency,
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protection, please note that pursuant to Section 136-29 of tire Code of the Town
of Qucensbury, any permit or approval granted which is based upon or is granted in
reliance upon nay material mistepresont.ation or failure to make a male'ial filet.or
circumstance known by or on behalf of an applicant, shall be void.
, I have rend the regulations With respect.to this application and agree to abide by these and all
rcquirotyenls pro Town of Qircenshury Sanitary Sewage Disposal Ordinance.
S g lature of respot sable person Date
1 \‘_0®
a
TOWN OF QUEENSBURY
BUILDING &_.CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name Q0AC- 171 a- N
Location _ =1t.R‘G\AGV.
Date 6., — 13.--i-,1 Permit # Z_LN-3914
SOIL TYPE(Sancl;Loam-Clay-
Results of Percolation Test-
(if applicable) Rate 'i .te/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Le gth
Length of each tre ch
Depth of trenches
Size of stone
SEEPAGE PITS: 'Num.'' ,(2)P F
Size . x ly ft.
Stone ze 1 ,
PIPING: Size Type
Bldg. to Tank r',
Tank to Dist. Box tick
Dist. Box to Field/P t - %\
Openings Sealed? _ No Partial
LOCATION/SEPARATI,
Foundation to Tank Vj feet
Foundation to Absorption 'C-, feet
Separation of Pits feet
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM ON PROPER :
(circle one)
Fr Rear - Left Side - Right Side
iddle Front - iddle Rear
SYSTEM USE APPROVED: 0
ilk
Arrived: ''_611, c.
Depar •. �i
Building Inspec 'r
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804 •
(518) 761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name t3fw3 i,iA
Location 1-AEtiJ('�tCY— C iRCt F
Date (0-17-1 Permit #7_'1 7394
SOIL TYPE:�SaLoam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone .
SEEPAGE PITS: Number-
Size - 9 ft. x ILA ft.
Stone size
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box n pC
Dist. Box to Field PRE Alt�3C
Openings Sealed? es ') No Partial
LOCATION/SEPARATIONS:
Foundation to Tank fQLOTeet
Foundation to Absorptions feet
Separation of Pits tr���t ,feet
Conforms as per Plot Plan Yes No
LOCATION OF SYSTEM ON PROPERTY:
(circle one)
Front - Rear - Left Side - Right Side
ddl e Fronts, Middl a Rear
MUNMENIS:
6EEVA �► t1Pc‘oiNr\ °
SYSTEM USE APPROVED: YES N�
Arrived:
Departed:
Building Inspector
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"I have seen or observed, or believe I saw evidence of, r---
all objects such as houses, wells, trees, fences, etc.,
shown on t . document. I also represent that I have
perso y asured the distances set for on the diagram."
IGNATURE DATE